Mechanical Ventilation lectutre Flashcards
(121 cards)
1
Q
Tidal volume (vt)
A
amount of air inhaled and exhaled
2
Q
Inspiratory Reserve volume (IRS)
A
maximum air inhaled over tidal volume
3
Q
Expiratory Reserve Volume (ERV)
A
max amount of air exhaled over Tidal volume
4
Q
Residual volume (RV)
A
amount of air left in lung after exhale
5
Q
Functional Residual Capacity
A
SUM of ERV and Vt
6
Q
Oropharyngeal Airway:
-location
A
- follows natural curvature of the tongue
- holds tongue away from throat to maintain patency
7
Q
Oropharyngeal Airway:
-what types of patient to use it on
A
UNCONSCIOUS patient who has an absent or diminished gag reflex
8
Q
Oropharyngeal Airway:
-what are the benefits? complications that it avoids?
A
Avoids the risk of nasal irritation and sinitus
9
Q
Nasopharyngeal Airway:
-location
A
- inserted into one nare
- maintains patency of hypopharynx
10
Q
Nasopharyngeal Airway:
- what does it limit the stimulation of?
A
gag reflex
11
Q
Tracheostomy:
-what type of patients to use it on?
A
-LONG TERM MANAGEMENT: 7-10 days
12
Q
Tracheostomy:
-advantages of having a trach for the patient
A
- more comfortable for the patient
- patient can eat and talk
- easier to remove secretions
- reduces decannulation
13
Q
Tracheostomy:
-two ways to insert the trach
A
1) OR surgical
2) percutaneous procedure- bedside
14
Q
Tracheostomy:
-two items to have at the bedside for safety
A
- obturator
- 2nd trach + a smaller size for accidental dislodgement
- vaseline gauze
15
Q
Tracheostomy:
-complications during insertion
A
- misplacing the tube
- hemorrhage
- laryngeal nerve injury
- pneumothorax
- cardiac arrest
16
Q
Tracheostomy:
-complications in management
A
- stomal infection
- hemorrhage
- fistula
- tube obstruction and displacement
- *SKIN BREAKDOWN!
17
Q
Tracheostomy:
-complications with removal
A
- days to weeks after:
- stenosis and fistulas
18
Q
Tracheostomy:
-when should sutures be removed?
A
-only in there for 7-10 days
19
Q
Endotracheal Tubes:
-location
A
- insertion into the trachea via the nose or mouth
20
Q
Endotracheal tubes:
-what type of patients to use it on
A
SHORT TERM management
21
Q
Endotracheal Tube:
-Indications for use
A
- protection from aspiration
- application of positive pressure ventiation
- high oxygen concentrations
22
Q
Endotracheal Tube:
-what happens if the air-filled cuff deflates?
A
-risk for aspiration pneumonia
23
Q
Endotracheal Tubes:
-advantages of use for healthcare professionals
A
First.
Fast.
Easiest
24
Q
Endotracheal Tubes:
- complications
A
- ORAL TRAUMA: broken teeth
- vomiting with aspiration
- hypoxemia
25
standard intubation equipment
- laryngoscope
- oral Endotracheal tube with various sizes
- ambu-bag and O2
- suction equip
- paralytic meds
- cap CO2 detector- turns purple to yellow
26
Rapid Sequence Intubation
-7 steps
(1-4)
1) preperation
2) Pre-oxygenate for 3-5 min with 100%
3) Pretreatment within 3 min of next step
4) give paralytics and sedatives
27
Rapid Sequence Intubation (RSI)
1) paralytics
2) sedatives
1) succinylcholine and rocuronium
| 2) Versed, ketamine
28
Rapid Sequence Intubation (RSI)
| -step 5
5) Protection and Positioning
- Sniff position
- Sellick maneuver (cricoid pressure) - BURP
29
RSI:
- Sniff position
- Cricoid pressure
- tilt back with neck hyperextended
- BURP: back, up, right, pressure on trachea
* closes off risk for aspiration
30
Rapid Sequence Intubation (RSI):
| -stepts 6-7
6) Placement of ETT (3-4 cm above carina)
- intubate less than 30 sec, if not, re-oxygenate
7) Post intubation management
31
Aspiration of as little as ____ mL of gastric content may result in significant injury to the patient
20
32
Prevention of Endotracheal Tube complications:
| -tube obstruction
- bite block
- humidify
- replace old ETT's
33
Prevention of Endotracheal Tube complications
| -Tube displacement
- secure tube
- restraints
- sedate
34
Prevention of Endotracheal Tube complications
| - Sinusitis and nasal injury
- Avoid nasal intubations
| - antibiotics
35
Artificial Airway Cuffs-
| -purpose
- small balloon inflated to prevent leakage of inhaled air past the tube into the upper airway
- CLOSED SYSTEM
36
Artificial Airway Cuffs-
| -Minimal Leak technique
-place stethescope over larynx and inject 0.5 ml of air into the cuff at a time until small inspiratory leak is auscultated
37
Artificial Airway Cuffs-
| -Minimal Occluding Pressure
inflate then decrease by 0.2 ml. when you hear an air leak increase to the point air leaks and trachea is sealed
"darth vadar " noise
38
how to suction a patient?
- give 3 100% breaths
| - do not suction for more than 10-15 seconds
39
What to do if ET tube pulled out?
- page doctor
- listen to lungs sounds
- call RT
40
what is mechanical ventilation
any means in which physical devices or machines are used to either assist or replace spontaneous respirations
41
Indications for mechanical ventilation
- relieve upper airway obstruction
- Acute lung failure
- PaO2
42
What must you give the patient when on Mechanical Ventilation
- sedation
| - neuromusclular blockade
43
Mechanical Ventilation:
| -Negative-Pressure ventilators
- "iron lung"
- applied externally to patient
- ** decreases atmospheric pressure surrounding the thorax to initiate inspiration
44
Mechanical Ventilation:
| -Positive Pressure Ventilators: (PPV)
-forces gas into the lungs to expand them
45
Mechanical Ventilation:
| -Positive Pressure Ventilators: (PPV) 2 types
1) Volume cycled
| 2) Pressure cycled
46
Positive pressure ventilators:
| 1) VOLUME CYCLED
- gas flows into lungs until a preset VOLUME of gas has been delivered
- constant tidal volume regardless of compliance and airway resistance
47
Positive pressure Ventilators:
| 2) PRESSURE CYCLED
- gas flows into the lungs until a preset PRESSURE is reached
- delivery of desired tidal volume is NOT guarenteed
48
Mechanical Vent. Settings
| -Trigger
-what causes the vent to deliver breath (pressure or flow)
49
Mechanical Vent. Settings
| -Sensitivity
determines the amount of effort patient must generate before the ventilator will deliver a breath
50
Mechanical Vent. Settings
- Sensitivity:
- if setting TOO LOW
- if setting TOO HIGH
- pt works harder to breath
| - asynchronus breathing
51
Mechanical Vent. Settings
| -Respiratory rate
-6-20
* key way to control CO2
adjust according to PaCO2
52
Mechanical Vent. Settings
| -Tidal volume
-volume delivered per ventilator breath
-500-800 mL
N (6-10 ml/kg/IDB)
ARDS (4-8)
53
Mechanical Vent. Settings
| -fraction of inspired O2 (FiO2)
% of air that is being delivered by ventilator each breath
21-100%
*must maintain PaO2 80-100 and SaO2 >90
54
Mechanical Vent. Settings
| -Positive end expiratory pressure (PEEP)
- prevents shunt
- keeps alveoli open to promote gas exchange
- AFTER EXPIRATION
55
PEEP normal value
3-5
| ARDS: 5-20
56
Mechanical Vent. Settings
| -Flow rate
determines how fast tidal volume will be delivered
57
Flow rate:
- LOW
- HIGH
- allows long inspiration
| - allows fast inhalation for longer exhalation
58
What type of flow rate does COPD want?
HIGH FLOW RATE
59
Mechanical Vent. Settings
| -I:E ratio
duration of inspiration to expiration
| 1:2
60
Mechanical Vent. Settings
| -Pressure Limits
-regulate maximum amount of pressure the ventilator will generate to deliver preset tidal volume
61
Positive End Expiratory Pressure
| -functions
- Maintain airway pressure
- Increases FRC
- improves oxygenation by opening collapsed alveoli at end of expiration
- decreases FiO2 to less toxic
62
minute volume (MV)
total volume of gas inhaled or exhaled over 1 minure
63
Peak Inspiratory Pressure PIP
airway pressure at maximum inspiration
| -AIRWAY PROBLEM : mucus plug
64
Plateau pressure
Pressure applied to small airways and alveoli during PPV
- Measured during an inspiration pause on the mechanical ventilator
* LUNG COMPLIANCE
65
Modes of Ventilation:
| -continuous mandatory volume (CMV) aka Assist control (AC)
-delivers gas at a preset volume or pressure
-patient CAN either trigger the ventilator or machine will give a breath on its own
-
66
CMV/AC
- advantages
- disadvantages
- indications
- guarentees a minimum minute ventilation
- can lead to RESP ALKALOSIS and Hypotension
- pts who need full ventilator support and need a steady vt
67
Example of a Ventilator Mode:
| -AC 16 (BUR)
Back Up Rate
| -if patient unable to trigger breathing
68
Modes of Ventilation:
| - Synchronized Intermittent Mandatory Ventilation (SIMV)
- a mix of MANDATORY breaths and ASSISTED breaths
- delivers preset volume or pressure while allowing pt to breath spontaneously
- "works out lungs"
69
Difference between SIMV and AC
-SIMV allows patient to breath without any support when they want to, AC allows support by ventilator
70
SIMV
- advantages
- disadvantages
- Indications
- guarentees minimun minute ventilation. Lower pressure than AC
- Increased WOB for patient-fatigue
- needed for patients who are hyperventilating or have high airway resistance
71
REVIEW AC and SIMV
AC- receive full support
| SIMV- receive partial support
72
Modes of ventilation:
| Pressure control ventilation (PCV)
- MANDATORY breaths only
| - patient CANT trigger ventilator
73
Pressure Control Ventilation (PCV)
- advantages
- Disadvantages
- Indications
- prevents excess airway pressure, avoids alveolar over-distention, leads to earlier weaning
- uncomfortable, requires DEEP SEDATION
- Pts with high risk barotrauma
74
Modes of Ventilation:
| - Pressure support ventilation (PSV)
- No mandatory breaths
- preset positive pressure on patients inspiratory efforts
- patient controls rate, flow, and vt
* * Pt has control of breaths!
75
Pressure support ventilation (PSV)
- adavantages
- disadvantages
- indications
- supports breathing and helps patients with a stable respiratory drive to overcome increased airway resistance, reduces their work of breathing
- apnea alarm is only back up
- assist spontaneous breaths in SIMV or helps weaning
76
neuromuscular blockade
paralysis of a patient using drugs that paralyze skeletal muscle but don't affect cardiac or smooth muscle
77
Uses of neuromuscular blockades
- aids in intubation
- acts by competing with ACh
- stops muscles from depolarizing
78
what must you give when you give a neuromuscular blockade?
* pt is paralyzed but fully CONSCIOUS
- GIVE SEDATIVE and PAIN control
- versed as an IV drip
79
Neuromuscular Blockade Nursing considerations
- patent airway
-ambu bag
ABGs
-position change and passive ROM
-Protect eyes with lubricant and eye-pads
80
```
Train of 4:
4/4
3/4
2/4
1/4
0/4
```
- less than 75%
-75%
-80% DESIRED
-90%
100%
81
Troubleshooting alarms
| DOPE
D- disconnections
O- obstructions
P-pressure/pneumothorax (check lung sounds and chest Xray)
E- equipment
82
why would an alarm say low pressure?
- patient disconnection
- tubing disconnection
- cuff leak
83
why would an alarm say high pressure?
- patient coughing
- secretions or mucus in airway
- patient fighting the ventilator
- increased airway resistance
- reduced lung compliance
- water in circuit
- kinking in the circuit
- problems with I/E valves
84
why would patient be agitated or in dis-synchrony on the ventilator ?
- secondary to overall discomfort-->increase their sedation
- secondary to air hunger-->adjust respiratory settings (vt, flow rate, ect)
-
85
complications of mechanical ventilators
- oral and dental damage
- nasal damage
- decrease in C.O
- barotrauma/voltrauma
- emphysema
- infection
- increase WOB
86
Barotrauma/Volutrauma
- alveolar overdistention with resiliant alveolar rupture and air leak
87
effect of mechanical ventilation on renal system
decreased urinary output d/t low perfusion to kidneys
| * tell Dr if
88
Effect of mechanical ventilation on GI?
- stress ulcers
| - give pepcid
89
When to draw ABGs when on a mechanical ventilator
- 30-60 min after ventilations begin
| * DO NOT SUCTION for 15 min before drawing ABGs. alters O2 values
90
what else should be checked besides ABG's
- Hgb
| * ensure the absence of anemia and adequate perfusion
91
*** what to do if:
| INCREASED PaCO2
INCREASE rate or tidal volume
92
*** what to do if:
| DECREASED PaCO2
DECREASE rate or tidal volume
93
*** what to do if:
| INCREASED PaO2
DECREASE FiO2 or PEEP
94
*** what to do if:
| DECREASED PaO2
INCREASE FiO2
95
Process of Weaning:
| WEANING
```
W-WOB
E- electrolytes
A- attitude
N-nutrition
I-infection
N-nonspecifc
G-gases
```
* * make sure to educate the patient
* * only do spont. breathing trial for 30-120 min
96
weaning methods
| 1) SIMV weaning
- gradual transition from vent to spontaneous breathing
97
weaning methods:
| 2) PSV weaning
PS mode at a level that achieves spontaneous vt
| -augments pt breathing with a + pressure boost during inspiration
98
ACUTE LUNG FAILURE
inability of lungs to maintain adequate oxygenation of the blood with or without impairment or CO2 elimination
99
Acute Lung Failure:
| Type 1
low PaO2 (
100
Acute Lung Failure:
| type 2
low PaO2 (45)
101
Acute Lung Failure management
- O2 >90%
- PaO2 45??
- ventilation: pH
102
Acute Respiratory Distress Syndrome (ARDS)
non-cardiogenic pulmonary edema
| -alteration of the alveolar capillary membrane
103
ARDS causes:
| DIRECT
- aspirate gastric content
- pneumonia
- near drowning
104
ARDS causes:
| INDIRECT
- sepsis
- trauma
- pancreatitis
- blood transfusions
- DIC
105
ARDS pathophysiology:
injury occurs--> inflammatory response--> immune system releases protein mediators--> this increase the permeability of alveolocapillary membrane--> allows large molecules to enter--> collapse of the alveoli and makes lungs less compliant (stiff)
106
ARDS progression:
| 1) Exudative phase
- release of INFLAMMATORY MEDIATORS
- within 72 hrs of injury
- alveolar edema and Type 1 epithelial cells (flooding)
- Xray changes in 24 hrs
- mediators cause damage to alveolar hypoventilation, V/Q prob, intrapulmonary shunting, hypoxemia
107
ARDS progression:
| 2) Fibropolierative phase
- HEALING begins
- granulation and collagen deposits
- fibrotic alveoli
- scarred pulmonary capillaries
108
ARDS progression:
| 3) Resolution phase
- REMODELING
- alveolar fluid goes to interstitium
- Type 2 epithelial cells multiply
109
ARDS S/S
- within 48 hrs
- restlessness
- HTN
- tachycardia
- SOB
- accessory muscle use
- lung sounds: clear, crackles, or rales
110
ARDS diagnostic findings
| -ABGs
- low PaO2
| hypoxemia: PaO2/FiO2 less than 200
111
ARDS diagnostic findings:
| -CXR
"white out"
112
ARDS diagnostic findings:
| -PA cathater
PAOP
113
ARDS Treatment:
-establish airway
-HIGH PEEP!! keep alveolar open
-sedate
-A-line to maintain BP
corticosteroids to help with membrane permeability
-nutrition: TPN
PRON POSITION
114
symptoms of respiratory distress associated with ARDS begin within __ hours of insults to lungs
24-48 hrs
115
what is happening at the cellular level to cause hypoxia in ARDS
leaking of alveolocapillary membranes
116
high levels of PEEP can cause what ?
Decreased C.O because high intrathoracic pressure
117
ARDS POSITIONING txt
* preferential blood flow occurs to the gravity-dependent areas of the lungs
* positioning is used to place the least damaged portion of the lungs into a dependent position
- prone
- rotation
118
ARDS positioning:
| 1) Prone
-improves oxygenation
119
ARDS positioning:
| 2) Rotation
-keep them on special beds 24-48 hrs
120
What would you do first to increase oxygenation in an attempt to decrease FiO2 when in oxygen toxicity?
Increase PEEP
121
Inadequate PEEP can increase the risk of:
Atelectrauma: open/close can cause alveolar damage.
